Extracts from a Lecture on the Laryngoscope

Attempts to examine the larynx by means of a mirror have, at different times, been made independently by various experimenter . One cf the first, if not the very earliest, of these attempts was made by a distinguished Fellow of this College-?I mean Dr. Babington, who showed bis instrument at a meeting of the Huuteriac Society in March, 1329?e., thirty-five years ago. The instrument was essentially the same as that now in use, and the following description of it was published in the third volume of the j Medical Gazette p. / Tt, consisted of *?' oblong peace of looking-glass set in silver wire, with a long shank. The reflecting portion is placcd againt' the palate, whilst the tongue is held down i y a spatula, when the epiglottis an the upper part of the larynx become visible in the glass."' The report odds that "tie Doctor proposed to c; il it thegloUiscope Dr. BaM?!g'.-.>n afterwards had his tr.irror made of polished atee), ai.d in oi.e he com-

ington, who showed bis instrument at a meeting of the Huuteriac Society in March, 1329?e., thirty-five years ago. The instrument was essentially the same as that now in use, and the following description of it was published in the third volume of the j Medical Gazette p. / Tt, consisted of *?' oblong peace of looking-glass set in silver wire, with a long shank. The reflecting portion is placcd againt' the palate, whilst the tongue is held down i y a spatula, when the epiglottis an the upper part of the larynx become visible in the glass."' The report odds that "tie Doctor proposed to c; il it thegloUiscope Dr. BaM?!g'.-.>n afterwards had his tr.irror made of polished atee), ai.d in oi.e he combined a tongue-deprejaor wi'h the mirror. Ho also baa one mirro.' of ovoid shape, which was convenient for use when the tonsils were enlarged. Dr. Babington tells me that he was in the habit of illuminating thf-throat by reflecting the light of the sun from a mirror held I i the ieft hand. It was long after Dr. Babington had published the account of his glottiscpe that Mr. Liston, in his " Practical Surgery," (1840,) referred to the use of a dentist's mirror for obtaining a view of the glottis.
MM. Trousseau and Belloc, in a treatise on Laryngeal Phthisis, which was published iu the yeaf 1837. refer to a speculum laryrtgis. It was made by M. Selligue, an ingenious mechanic, who had himself suffered from laryngeal phthisis. The instrument consisted of two tubes, through one of which the light was thrown on the glottis, while through the other the image of the glottis wa3 refleeted Jrom a mirror placed at-its gutteral extremity. I he authors state that the instrument was very difficult of application, and that no one person in ten could bear its introduction.
The late Mr. Avery worked long and successfully in the construction of a laryngoscope aud other instruments for the examination of internal organs, but ho published nothing on the subject.0 In the year 1844 the late Dr. Warden invented a prysm&tie speculum, with which he succeeded in seeing disease of the glottis in two cases.f It is a well-known fact that the first experimenter who succeeded in obtaining a view of his own larynx is a distinguished professor of music in this tows. M. Garcia. M. Garcia had long studied the apatomy aud physiology of the larynx as the orgau of voice, and he had a great desire to see the movement of the living larynxt At length he obtained the desired object ly a very simple plan. Standing with his back to the sun. he held a looking-glass in hi. left hand before his face; the sun's rays were reflected by the glass into his open mouth. Then he introduced a deutist's mirror, previously warmed, into the back of his mouth, and thus he saw the reflection of his larynx iu the looking-glass M. Garcia gave the results of his observations in a vcy interesting paper entitled " Physiological Observations on the Human Voice," which was published in the " Proceedings" of the Royal and energy. Ilo soon made the important step of adopting the large ophthalmoscope reflector as a means of concentrating artificial light, thus making the laryngoscope available at all times as a means of inspecting the larynx, and of guiding the hand in the application of local remedies. Czennak soon saw, as he s:iys, the practical value of the instrument, and he has been most energetic and most successful in his efforts to secure its recognition by the ?vhoie civilized world.
It apptars to ma that, without injustice to those who bad pre" * Introduction to the Art of Laryngoscopy. Ry pr> Yearsley, 1862. f Bnfcssh and Fewife Mediea-Ohirarfieft! Rorfow. Jea,, 1863. p. 10, ceded him, Garcia's claims to originality in the matter of aotolargyngoscopy being obviously quite distinct and indisputable?
Czertnak may be considered to bo the discoverer of the art of laryngoscopy in its application to the diagnosis and treatment of disease. He was also the first to practice the kindred art of rhinoscopy. Sydney Smith, in discussing the rival claims of discoverers, has said, " That man is not the first discoverer of any art who first says the thing; but he who says it so long, and so loud, and so jplearlv, that he compels mankind to hear him?the man who is so deeply impressed with the importance of his discovery that he will take no denial; but at the risk of fortune and fame, pushes through all opposition, and is determined that what he thinks he has discovered shall not perish for want of a fair trial." On grounds such as these?not of priority in time, bat in persevering and successful efforts to render the method practically available?
Czermak has established strong claims to be considered the discoverer, as he has unquestionably been the great improver and the great teacher, of the arts of laryngoscopy aud rhinoscopy, in their application to the diagnosu and treatment of disease.s I propose now to describe the method of using the laryngoscope. And, first as to the mo le of illuminating the throat. The plan ' ? which is generally adopted is to reflect the light of the sun or of j a lamp into the throat by means of h concave mirror, which is ! fixed on the forehead or iu front of one eye of the operator.
The operator always sits opposite to the patient. When sunlight is used, the patient is placed with his back to the sun. When a lamp is employed, it is placed usually to the right side of the patient'6 head and on the same level, or a little above. In using artificial light, it is unnecessary to darken the room more than may be done by simply drawing down a blind, so as to lessen the glare of daylight. Now the question arises, should the reflector be perforated and placed in front of oue eye, so that we look through it into the patient's throat, or is it better placed on the forehead just above the eyes? in which case it is Unnecessary to have the mirror perforated. I believe that the best position for the reflector is above both eyes and not in front of one, and as this is a point of considerable importance, I must give the reasons for my belief.
With the reflect* r on tT;e forehead we avoid the discomfort and inconvenience resulting from the effort required to keep ane eye applied to the opening in the mirror. We have the free and unimpeded use of both eyes, and we consequently find it much easier to direct the light into the patient's throat, to introduce the laryngeal mirror, and to practise any other manipulation that may be required either fur diagnosis or treatment. Another incidental advantage attending the position of the reflector on the forehead is, that we thus get a more extended movement of the reflector in all directions. This free movement enables us readily to change the direction of the Sight when we are examining our patient, and it also facilitates a very simple mode of auto-laryngoscoj>y of which I shall presently have to speak. The question then arises are there advantages to be gained by looking through a perforated reflector which in any degree compensates fur its manifest inconveniences? I know of none, and I believa that none exist. The practice of using a perforated reflector was borrowed from the ophthalmoscope ; but the conditions which attend the exploration of the interior of the eye through the small opening of the pupil are very different from those which exist when we arc looking * Dr. Christie, of Aberdeen, claims for Levret the original suggestion of such aa instrument. L'art dee Acoouohcmenta, P*rU, IH3. through the wide open mouth at an image of the larynx reflected from a mirror of considerable size. In tho latter case there is nothing gained by looking through the centre of a perforated reflector. I have fully tested .this, not only in the examination of the larynx, but also by an experiment of this kind. Place a stethoscope, with the ear-piece downwards, on the table in front of you.
Hold a laryngeal mirror obliquely over the upper end of the stethoscope, so as to reflect the interior of the tube, throwing the light of a candle on the mirror by means of the concave reflector placed at one time on the forehead, at another iu front of one eye. You will find that, as regards the facility of illuminating the interior" of the tube and seeing its image in the mirror, the position of tho reflector makes not the slightest difference.
I have met with very few persons who have tried both methods, fail to appreciate the gre?t convenience and advantage of having the -reflectoi on the forehead rather than in front of one eye.
Some who have become accustomed to the Litter plan are unwilling to change it. Czermak not only keep.* the reflector iu front of the right eye, but he holda the apparatus between his teeth?a practice iu whi -h he has found very few imitator*. M.Garcia0 states, with regard to the use of a perforated mirror, that ha tried it in order that Drs. Sharpey and Williamson might observe his larynx while he ?xpe;i utmle-l upon himself. He found, however, that this was not attended by any marked advantage. They could see the leflected image of his larynx aa well a* by looking over the top of the mirror as by looking through its perforated centre. I made th? same observation when looking into Czsrmak'# throat while he was using his auto-laryn&;oscopic apparatus ; I could see his larynx as well by the side of the reflector as through it? centre. When I am examining the larynx of a patient, if I wish to make the par$8 visible to another, I can rea IHy da t. s i v turning the face of the laryngeal mirror slightly towards one side, and directing the observer to look over my shoulder at the mirrot in the throat. In order to see the image in the larynx it is unne* cessary that the eye should be even near the margin of the reflector much less is it neccssarr that thf eye should look through th* centre of the reflector.
The reflector "vh n in fro ,trf the aye, therefore, being a source of much discomfort'and inconvenience, without any compensating advantage, is better placed on th?i forehead just above the eyes.
The faueial cr laryngeal mirror is made of different forms? square, with the aqgles rounded off, circular or oval. The form of the mirror is of little'consequence. I find, however, that a circu? lar mirror irritates the ba; k oi the ph rynx le:-'s than a square one -I therefore prefer the circular luvrn. Silver' glass mirrors are to be preferred to those madf of t'eel t .!?? et rtal. Metallic mirrors soon '????* their polish, '-.nd they quickly cool, and thus become dimmed by the breath.-'I he mirror is to oe warmed by holuiug it over the lamp or by dipping it into warm water. Its temperature should be tested by bringing it in contact with the cheek or the hand of the operator.
It should be warm enough to prevent being dimmed by the patieut's breath.f There are two reasons for not over-heating the mirror?first, the patient's mouth w ill be burned ; and, second, the silvering of the mitror will be spoiled.
Tne mirror is to be held like & pen, bctw*??r> t.V thumb and two fingers, and introduced bo as to slightly raise the uvula and soft palate. Care must be taken to avoid touching the tongue, and as *Notie? eur l'lnveiitioa du Laryngeaeope, nar i'&uu.u lliohard. Paria, 1861. p. 14.
fDr. Buzzard (Lancet, August 1864,) advises the application of a little dilate glyoerioe to prevent the aqueous deposit on the mirror# much as poasible the back of the pharynx, with the mirror, these being the most sousitive parts within the mouth. The hand of the operator may be kept steady by resting the third and fourth fingers on the chin of the patient.
I have said that we must not touch the tongue with the mirror ? ' but how is this to be avoided? You will find that, very generally, as soon as the mirror is introduced between the teeth, the tongue involuntarily rises towards the roof of the mouth, so as to come in contact with the mirror and obstruct the view ; and, in fact, the tongue is one of the most frequent aod most serious impediments in the way of laryngoscopy. There are various modes of dealing with this unruly member.
In some few cases the pationt has sufficient control over the tongue to hold it down by a voluntary effort while the laryngeal mirror is being introduced. This power, however, is rare!y acquired until after a considerable amount of practice, and in mos* instances the tongue has to bo kept out of the way by some mechanical means. The plan which usually succeeds best is to hold the tip of the tongue between the thumb and the forefinger, and to draw it gently forward over the lower teeth. This may be done by the operator with his left hand, or by the patient, the thumb and finger which hold the tongue being covered by a cotton glove, or bv a towel or handkerchief.
In some cases a metallic tongue-depressor may be used with advantage, or the tongue may be pressed down by the fore-finger of the operator's left hand. But it will usually be found that one effect cf depressing the tongue in front is to push it backwards at .lie base, so that it nearly or quite touches the back of the pharynx, thus intercepting the light; while another effect is to make tho tongue arch upwards, so as nearly to touch the roof of the jnouth. This arched position of the tongue obstructs tho passage of the light to and from the larynx ; often, too, it brings the tongue in pontact with tho mirror, and this excites nausea.
For thesi reasons the attempt to depress the tongue is usually Jess successful than its gentle traction forwards.
I have bef'iro said that the laryngeal mirror is to be introduced so as slightly to raise the uvula and soft palate. Tho uvula must not be allowed to project below the mirror. The end of a long uvula hangirg below the mirror has its image reflected in the glat-s, and this obscures the view of the larynx. The uvula and the soft palate are the least sensitive parts with which the mirror can come in contact.
The posterior wall of the pharynx is usually more sensitive, and care should be taken to disturb it as little as possible. Frequently, however, the pharynx bears the touch of the mirror as well as the uvula and soft palate.
The mirror being placed in an oblique position below the palatei we usually at 0L.ce obtain a view of the larynx. A little practice will enable you to make such changes in the position of the mirror, or of the patient or in the direction of the light, as may be required to bring the parts fully into view. It should be borne in mind that the larynx, as it appears in the mirror, is reversed; that we get the same view a3 we have when, examiuing tho larynx aftor death, we look at it irom behind. The arytenoid cartilages are nearest to the eye; the insertion of the vocal cords into the thyroid cartilage is more distant. Wo also see the anterior wall of the trachea as if we were looking into the tube from behind. ^ i"* see that during inspiration tefc glottis is a wide triangular opening of considerable size, the vocal cords being of a pearly white color. Paring speaking?as in pronouncing the syllable "eli"?the glottis closes, and the cords vibrate with the impulse of the expired air.
It is important to practice the introduction of the laryngeal mir-ror with the lift hand as well as with the right. In applying 1 iocftl remedies to the larynx the patients i* instructed to rnaninu-| late his own tongue while the operator, holding the inir: r with the left hand so .is to obtain a view of the larynx, uses Via rijtht ! hand for the introduction of tha brush or other instrument.
But how does the throat bear the contact of the mirror? D -is not its introduction excite retching r>?l cougb and dyspnosa, and other unpleasant sensation*? These questions are often asked by those who have li;>d no experience in laryngoscopy; but those who have experience are unanimous in declaring that, in the great majority of cases, m <ie of ti ' se unpleasant results attend tin?
introduction of the mirror into the fauces. In some instances* I however, we meet with difficulties in the use of the instrument. | I will briefly refer to some of these, and will give some hints as to ; the best mode .of meeting them.
First, then, some parsons have a propensity to throw the tongue : forcibly upwards towards the roof of the month; arid they do this with a provoking pertinacity just as the mirror is being introduced between tho teeth. This p.*i iuti uf the tongue offers a serious impediment to the introduction of tho mirror, and the obstruction is gTcater in proportion to the size of the rebellious tongue. It is usually a-result of nervousness on the part of the patient, and is I sure to be made worse by any appearance of potulence in the ope-' rater. The better plan is to endeavor to reassure the patient.
Sometimes the occupation of holding his own tongue has a good ! affect by diverting his attention, and occasionally, while be ia i holding the tip of his tongue, you may depress the dorsum with a | spatula or with your finger. In some instances, after making one j or two attempt?, it is better to defer examination to a future day. ! After two or three sittings, there is usually less nervousness, and the tongue comes more under control.
[Dr. Watson, after hearing this lectur?, told me that in the case of patients who' have this tendency t<> arch up the tongue, and sa to prevent the examination of the fauces, he directs them to practiio by sitting in front of a looking-glass with the mouth open. The inspection of the tongue, while they are endeavouring to acquire the power of controlling its movements, is found to be a great assistance.] Another impediment to the examination 01 the larynx results from unusual senaitiveuess of the fauces, so that-the touch of the mirror excites contraction of the pharynx and r ?tching, This excessive sensibility is common when the fauces are in a state of inflammatory congestion ; so thru, seeing the throat engorged and red, we may anticipate a difficulty in the examination of the larynx. There are two mode's of lessening the sensibility of the throat in such eases. 0::e is, to d'>??>.? t the patient to keep a lump ot ice in his mouth fo; ten oi' fifteen minutfe before the examiij don, and as the icc n Its, o swallow the c-dd water. Another, ! arid I think a mor< eifr.-tua plan, is to put twenty drops : c' :i-| roform on a haodk'.roV ; i let Lira inhale it for a minute: j ! have found this successfnl in quieting the moat irritable throats, i and that without rendering the patient in the iea?t degree clrow-y | or uncomfortable. 'The bromide of potassium.-when $w d lowed or : used as a gargle, has long been supposed to have the effect of I lessening tin reflex sensibility of the fauces. but in the few case8 ; in which I have tried it for this purpose it has appeared to be quite ! inert: Semeledtr st^fea, ton, that he has not obtained tbo desired i ' re r.ir from this >V;:.
It will usually be found that the repeated introduction of the faucial mirror at intervals of a day or two has the effect of lessening the sensibility of the throat, so that after a short time the roost sensitive throat becomes tolerant of the mirror.
I have tVu, (1 diat patients laboring nuder acute Ian nyiiis and other organic diseases which are attended With much suffering usually bear the examination well, and often better than othprs who have but trifling ailments, or none at all. The man .who is threatened with suffocation will submit to any proceeding which affords him hope of relief, and the distress in his larynx is so great that he is sc. rely conscious of the trifling irritation caused by the fauoial mirror ; so true is it that "Where the greater malady is fixed The lesser is sotirce felt." I'nla'g -ment of the tonsils may render the examination of the larynx diftl-nlt 01 impossible. A srndl mirror m iy be used when the enlargement is not excessive ; but if the t< nsils are so milch enlarged as to touch each other, a laryngoscopy examination is impract'cable.
The epiglottis is some times very long, and projects obliquely downwards and backwards, so as to make it impossible to throw the light beneath it, and to get a view of the larynx. The arch of the epiglottis too, is sometiii es so contracted as to obstruct the entrance of the light.
Keme'edei0 gives us the jesu't < f his experience that in about 25 per cent, of adults he got a perfect view of the larynx easily at the first examination ; it> about 6 per cent, it was impossible to see the larynx at all ; in the remainder be succeeded more or less completely after repeated examinations. In children from two years of age and upwards the proportion of failures is much greater.
In the practice ol auto-laryngoscopy, whether 111 tne examination of one's own larynx or that of others,it is of primary importance that the operator should have the power of readily changing the direction of the light, so as at once to adapt it to the varying position of the body, which is often required for the thorough exploration of the larynx. A feebler light which can readily be reflected in any' required direction, is of more practical value in laryngyscopy than a stronger light which is fixed. Some laryngoscopist^ on the continent, and Dr. Walker of Peterborough, do not use the reflector for the purpose of lighting the throat, but in place of it they get a direct illumination of the fauces by means of a concentrated fixed light. A globular buttle of wate r in front of a lamp is used as a powerful condensing lens.
In this way, certainly, a very bright light is ob'ained ; but the objections to this mode of illumii.ation are?1st, that the apparatus is clumsy, and cannot be carried about; and, 2nd, the chief objection is that the direction of the light cannot be readily and instantaneously mado to follow the movementsof the patient's head The fact of the light moving with the movements of the operator, which some consider an objection to the method of illuminating the throat by means of the reflector on the foreheadi dees, in fact, constitute one of its chief advantages.
With regard to the source of the light, I find it not difficult to see and to demonstrate my own layrpx, as well as to examine the larynx of another, by the light of rn ordinary candlc; but a blight light readers the examination much easier and more satisfactory. The bes^ artificial light is a moderator lamp, or an argand gas-burner. The light may bo much intensified by placing a metallic reflector behind the lamp, and a bull's-eye condensor at t: e proper focal distance in front, the flat side of the lens being next the lamp. I find that with a single bull's-eye condensor I -Die Laryngoskopie und ihre verweftiung fur die Artzliehe Praxis.
Von Dr. Friedrich Semeleder. Wien. 1863. 14 get a better light than with To'noid's condensor, wln'cli consists of three lenses in a brass tube, and which is a niore cumbersome as well as a more costly apparatus.
Aii observers agree in opiniou that the light of the sun, when it can be obtained, is the best means of illuminating the throat.
The patient sits with his back to the sun, aod the operator directs the light into the throat by means of a reflector. For this purpose the rcflector need not be concave; n flat surface will give sufficient light. In using a concave reflector with sunlight, you mnst be careful not to burn the throat by concentrating the rays into a focus. Solar caustic, be it remembered may be made more powerful than lunar costic. [Since this lecture was given I have foutvl that the best mode of using sunlight in laryngoscopy is to place a looking glass in such a position that it shall deflect the sun's rays on the frontal reflector, but leave the eyes of the operator in the shade. In this way we avoid the serious iueonvenience which results from exposing the eyes to the direct rays of thesun. Both the patient and the operator are in the shade, a column of light being turned upon the frontal reflector l?y the looking-glass.j With sunlight it is not absolutely necessary to use the frontal reflector The patient may face the sun, so that the rays fall directly upon the laryngeal mirror. But here, again, the advanj tage of the reflector coi sists in the facility with which it enables | you in a moment to change the direction of the light The reflector on the forehead is a very useful mea s of lighting rh? throat for the purpose of examining the tonsils, p.date, and pharynx. Placing a lamp or a candle by the side of the patient, or using sunlight when it is available, the operator, with the reflector on his forehead, throws the light into the throat, aDd has both bis hands free to depress the tongue and to apply caustic or other local remedies. In cases of diphtheria and scarlatina, by this method of illumination a thorough examination of the throat can be made in s much shorter time than by the ordinary method, and without the necessity of raising the patient's head from, the pillow. The operator in this way runs less risk of infection from inhaling the patient's breath, or from the morbid secretion", being | coughed into his face.

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In the presence of a learned assembly such as I have now tha I honor to address, it is scarcely necessary to assert, that if in tha laryngoscope we have an impovtr t aid in the diagnosis of laryngeal disease, such aid by no means superfluous or uncalled for. The experience oi'evr-' practitioner will enable him to recall cases iri which <re has ;?f.ed the most painful doubt as to tha j nature of dtsei.?? -it1 th? :nrynx. Mr. Porter, writing in tha i year 1837." H.iw is a men of -experience, when ho meats 1 with a ca>H of hnytigsa' disease, to know whether it is caused by j an oedematous m ;:tt "j of the sub-mucous tissue?by a chronic thickcniug of n.-oous membrane itself?by laryngeal ulceration?by destruction of the cartilages?by the presence of abscess or tumor,'or by another of those numerous affections which dissection so frequently si ov> us to be the occasion of death ? And j he suggests that " perhaps by reason of the difficulty of the sub-! ect, is will b< long before we possess the same accuracy of in forj nation >vith reference to affections of the windpipe that has been i attained in other diseases/' What, now, has been the effect of that ? inpie contrivance, the laryngeal mirror? May it not be aid withoutexaggeration that it has rendered the diagnosis of the diseases of | the larynx more simple and more certain than the diagnosis of the diseases of any other internal organ? In fact the larynx has ceased to b< an internal organ, in the sense of being hiddeu from view, for it ha.^ been brought within tho range of vision. And the answer to Mr. Porter's question is simply tbiy, that the man of experience has now only to look into the larynx, and lie will see what is the form of a disease with which ha has to deal.
In my next lecture I propose to give some illustrations of the valuable aid which the laryngoscope is capable of affording in both the diagnosis and the treatment of disease. During the few minute* that remain to-day, I propose to advert, very b:ieily to the subject of rhinoscopy. Rhinoscopy.
Czermak, in his first publication on the laryngoscope, pointed out that the same method of examination was applicable to the inspection of the posterior surface of the soft palate, the posterior openings of the nasal fossa?, anil the superior parts of the pharynx.
In the practice of rhinoscopy the patient should sit erect, without throwing the head back, while the light is thrown into the mouth by the frontal reflector. The tongue is to be kept down by means of a metallic depressor, which may be held either by the operator or by the patient. A small mirror is required, and it is better made of glass than of metal, on account of tha rapidity ?with which a metallic mirror cools and condenses vapor on its surface.
I have two circular mirrors, which I find very convenient for rhinoscopy, one the size of a three-penny pi see, the other the size of a sixpenc?.
When you are about to introduce the mirror, the patient should be directed to breathe quietly. A deep inspiration draws the uvula and soft palate upwards and backwards, and so interferes with the examination. The mirror :s to be introduced by the side of the uvula, beneath the palate, with it? surface directed upwards and forwards. The facility with which the examination can be made depends maitjiy upon the space which exists between the ! palate and the posterior wall of the pharynx. When the interval i is a moderately wide one, the mirror can be introduced without | touching the uvula or palate, and the posterior openings of the nasal fossa?, the turbinated bones, the opening of the Eustachian tube, the septum narium, the roof of the pharynx,?all these parts ] may be distinctly seen.
In some cases the examination is facilitated by drawing the uvula and palate forwards by means of a blunt hook; but this is better avoided if pot-sible, for it is always attended with much discomfort, and frequently the contact of the hook excitis cnntract'on of the palate, which is then drawn upwards and backward8 svfls C' mp'e ely to obstruct the view. The most successful rhinoscopy examinations that I have made, have been accomplished ?without touching She uvula and soft palate. Very valuable information nay sometimes be obtained by rhinoscopy.
Last year I was constated by a gentleman, twenty-four years of age, who had complete obstruction of the right nostril. It had commenced two years ago, after a severe cold ; and it had steadily increased until, at tha ?.nd cf about a year, it was so compete t!ial he was unable by an effort either to inspire or to expel air through the right nostril. The left nostril remained pervious, but in consequence of the obstruction on the right side the"patient habitually kept his mouth open, respiration being impeded when the mouth was jthul ; and the voice had somewhat of a nasal character.
Examination of the nostril in front discovered no obstruction, nor was any abnormal appearance visible on examination of the palate and pharynx in the ordinary way through the "open mouth.
Ha had a throat favorable for rhinoscopy: a small uvula, with the soft pa'ate at some distance from the back of tha pharynx, ao that Hie mirror could be introduced without disturbing these p*rts The left nasal fossa was quite normal, but tha ri^ht wag seen to be completely obstructed by a tumour, apparently of globular r V JTL..'--M form, having a slightly granular surface and a yellowish-green color. It touched th? floor and septum of the nose; and i-xternally it pressed upon and concealed the turbinated bones. I could touch thp tumour wi'h a bent probe introduced behind tho palate. I now asked hiy friend and colleague, Mr. John Wood, to see the patient with ma, and to device a plan for removing the tumour.
He introduced -t pair of slender curved polypus forceps through the anterior opening of the nostril, grasped the tumour, and as he was drawing it forward there was a sudden rush of a glairy fluid, like white of eg?j, and some membranous shreds came away between the blades of the forceps. The patient felt immediately that the obstruction was gone. On rh'noscopie examination the tumour had disappeared : the turbinated bones were plainly visible; and on the under bide of the middle turbinated bone there wa3 an abraded surface, from which, apparently, the tumour had been torn, Tho tumou/ bad evidently been a globular cyst containing fluid. On the second day after the operation a portion 01 tao cyst wail came away. This T have preserved, it is smooth on its inner concave surface, but uneven on its outer surface, by which apparently it had been attached to the mucous membrane. During tho first few days after the operation, the abraded surface of the mucous membrane was covered by a purulent secretion ; this quickly healed. The patient has lost all sense of obstruction in the nostril; he can breathe comfortably with the mouth closed; and the voice has recovered its natural tone.
The practical value of rhinoscopy in this case car. scarcely ba called in question. It is doubtful whether by any other mode of examination tho position and nature of the tumor could have been determined with sufficient certainty to warranters operation " for its removal. I wsib relating this case to a friend, who remarked that my patient had mora reason to congratulate himself than one a'xiut whom he was consulted. One nostril wai obstructed, and it was supposed that a polypus was the cause of obstruction. A surgeon had made an unsuccessful attempt to remove the supposed polypus by the forceps; thia caused much suffering; and it wms at last discovered that the obstruction was due to thickening > f the turbinated bones.
Czermak, in the last German edition of his work, gives a pood illustration cf the value of rhinoscopy in correcting an erroneous diagnosis. A young man, deaf on the left side, was found to have a tumour at the back of the nostril, which conveyed to the finder the impression of a polypus. An operation whs contetiiplated, but a rhinoBCopic examination discovered a taperii.g swelling of the mucous membrane, r early as th: ; ".<? the finger. surrounding the orifice of the left Eu.-t ishir tube; also great swelling of the middle nnd inferior turbinate" bon^a; but no polypus, nor any tumour which an operation rould have removed or lessened.